Discordant couples

If a couple in which the man is infected by the human immunodeficiency virus HIV and with the aim of having children they decide to have sexual intercourse without a condom, then he risks infecting his partner.

It should be borne in mind that these couples, who we call serodiscordant (SDCs), despite being informed of preventive behaviours, present a rate of 6.1% of infections in women. This situation occurs most often in couples who had previously had intercourse without a condom and in which the man had a low immunity

(1). International organizations recommend the use of condoms as the best prevention for HIV transmission and therefore this limits the ability to achieve a pregnancy in these couples.

In 1992 Augusto E. Semprini (2) published an article about performing artificial insemination with washed sperm from HIV-infected men, in which no transmission of infection was detected; henceforth, the usefulness of the sperm washing technique has been analysed and it has been seen that there is no transmission of the virus to either the partner or the child.

This technique began to be applied in Spain in 1994. On May 31, 2002, the “Assessment Commission on human assisted reproduction techniques in Catalonia” published a document intending to establish a position to help meet the demands of users and which is compatible with the ethics and good practice of professionals. However, until now, no infection of the partner related to this technique has been reported.

It is true that the risk of heterosexual transmission is very low (3) when the man is on combination antiretroviral therapy and maintains undetectable plasma viral load. That is why some authors propose allowing unprotected sex during the fertile days in specific situations (4), but as up to 10% of men with undetectable plasma viral load may have virus in semen (5, 6), the residual risk of sexual transmission should be considered even when no virus particles are detected in blood.

Therefore, in our setting, where there is access to assisted reproduction for serodiscordant couples, they should be considered the method of choice.

 

If we look at the results of assisted reproduction techniques in these serodiscordant couples, we can see that the results are similar to those of the general population. Before applying the assisted reproduction techniques it is important to optimize the clinical control such as an assessment of the clinical and immunological stage, viral load, antiretroviral (ARV) treatment and adherence thereof. The patient should receive the antiretroviral treatment in accordance with the recommendations for the treatment of the infected adult, with instructions that take into account the experience of its use during pregnancy and its teratogenic potential, excluding restricted use drugs during pregnancy.The assessment and adjustment of treatments for prophylaxis against opportunistic infections should also be made. There are no limiting viral load or CD4 levels, but stabilising the infection should be regarded as a goal. A report from a specialist in internal medicine or infectious diseases will be requested (less than one year old) which must be done by the specialist who monitors the infected woman. This should include data on the current status of the disease, the CV plasma and CD4 lymphocyte count. In addition, the ARV treatment being received should also be specified as well as the history of opportunistic infections or other complications associated with HIV and whether she is carrying on with other concomitant treatments.

 

We should also bear in mind that there is no contraindication for reproductive treatment for other reasons (eg because of the use of ribavirin in the last 6 months)

We will conduct a baseline study of fertility on both partners in order to detect the existence of other problems and indicate the most suitable technique.

We will hand over a specific informed consent signed by both partners, detailing the risks of the technique to be carried out and the concept of reducing (not eliminating) the risk of HIV infection. (7)

Then, we will perform a routine semenogram and proceed to carry out a long sperm washing to remove the presence of virus. In all cases, the sample will be cryopreserved (regardless of the origin of the female gamete). After the cryopreservation of the sample, part of it should undergo an HIV-PCR to rule out possible contamination of said sample to be used. This will be done before the start of the cycle. An aliquot of the cryopreserved sample will be sent to an outside laboratory to confirm the absence of viral particles after the sperm washing by HIV-PCR.We will begin the treatment on the woman once we have the PCR result and provided it is negative.

Previously, artificial inseminations were performed with semen processed and analyzed the same day. Today, for various technical aspects, you cannot obtain the PCR result on the same day that the man leaves the fresh sample so we advise performing IVF-ICSI as the technique of choice.

The assisted reproduction laboratory must have the right structure and materials to process these samples independently and with specific measures to prevent possible contagion from other samples or from people who handle them.

With regard to the fertility of HIV positive men, there are studies assessing semen quality and they observe that semen parameters are significantly affected by the presence of HIV infection, particularly in relation to CD4 levels. There seems to be no correlation between viral load, the number of years since diagnosis or the use of antiretrovirals (8).

We cannot see the real impact of this alteration in the fertility capability of these couples, as it is recommended that they avoid unprotected sexual intercourse.

During the cycle the woman should undergo an Ac-HIV and an HIV viral load analysis to rule out recent primary infections that may have arisen before the embryo transfer. In addition, at 15 days from the transfer, the patient should repeat an HIV viral load test to rule out a secondary infection following the procedure.

The follicular puncture and embryo transfer techniques are similar to any other IVF cycle and we can say that the results are good.

Bibliography

  1. Romero J del, Castilla J, Marincovich B, Hernando V, García S, Rodríguez C. Mujeres que son pareja de un varón infectado por el VIH: descripción de sus características y valoración del riesgo. Aten Primaria 2004;34:420–426. 206.
  2. Semprini, A.E., et al., Insemination of HIV-negative women with processed semen of HIV-positive partners. Lancet, 1992. 340(8831): p. 1317-9.
  3. Del Romero, J., et al., Combined antiretroviral treatment and heterosexual transmission of HIV-1: cross sectional and prospective cohort study. BMJ, 2010. 340: p. c2205.
  4. Barreiro, P., et al., Is natural conception a valid option for HIV-serodiscordant couples? Hum Reprod, 2007. 22(9): p. 2353-8.
  5. Nicopoullos, J.D., et al., A decade of the sperm-washing programme: correlation between markers of HIV and seminal parameters. HIV Med, 2010. 12(4): p. 195-201.
  6. Marcelin, A.G., et al., Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma. AIDS, 2008. 22(13): p. 1677-9.
  7. Guía práctica para el seguimiento de la infección por VIH en relación con la reproducción, embarazo, parto y profilaxis de la transmisión vertical del niño expuesto. Grupo de expertos de la Secretaría del Plan Nacional sobre el Sida (SPNS), Grupo de Estudio de Sida (GeSIDA) / Sociedad Española de Ginecología y Obstetricia (SEGO) y Sociedad Española de Infectología Pediátrica (SEIP).
  8. Nicopoullos JD, Almeida PA, Ramsay JW, Gilling-Smith C. The effect of human immunodeficiency virus on sperm parameters and the outcome of intrauterine insemination following sperm washing. Hum Reprod 2004;19:2289–2297.

Last Updated: November 2017